mix of non-trauma patients and may undermine the sustainability oflarge urban TC. To assess the potential burden of the trauma patienton the urban Level ITC we evaluated the payer-mix of trauma patientsrelative to non-trauma patients at different levels of trauma care in amature state-wide trauma system.

Methods: Patients admitted to a hospital in the state over a 3 yearperiod were classified as either trauma (ISS $ 9) or non-trauma and byinsurance status as either commercial insurance (CI) (e.g. managedcare) or non-commercial insurance (e.g.Medicaid or self-pay). Medicare patientswere excluded from analysis. Data werecompared using x2 analysis.

Results: There were 10,386 trauma admis-sions and 474,944 non-trauma admissionsto 87 centers. Trauma patients were lesslikely to have CI than non-trauma patients(69% vs 74%, p , 0.001). The proportion oftrauma patients with CI treated at the LevelITC was significantly less than at other cen-ters (graph). However, trauma patientstreated at the Level I TC were far more likelyto have CI than non-trauma patients treated at this same center(graph). By contrast, there was no relationship between payer andtrauma status at other levels of care.

Conclusions: Utilization of trauma triage guidelines results in theadmission of a disproportionate number of patients with CI relative tonon-trauma patients to this urban Level I TC, an effect due to referralsfrom outside the urban area and across the state. In this environment,designation as a Level ITC may actually improve care for inner citynon-trauma patients by ensuring the ready availability of acute careservices that follows designation as a TC and by means of crosssubsidization of non-trauma care through trauma care reimbursement.

Variations in the care of the head injured patientEM Bulger, AB Nathens, FP Rivara, DC Grossman, M Moore, GJJurkovich. University of Washington, Harborview Medical Center,Box359796, 325 Ninth Ave., Seattle, WA, 98104, USA

Introduction: In spite of the availability of evidenced based guidelinesfrom the Brain Trauma Foundation, the optimal management of thehead injured patient remains controversial. Perhaps the most contro-versial guideline is the recommendation for intracranial pressure (ICP)monitoring for patients with a GCS # 8 and an abnormal head CTscan. We sought to evaluate the variations in care of head injuredpatients and to determine the impact of ICP monitoring on outcome.

Methods: Data were collected from 34 academic trauma canters ofthe University HealthSystem Consortium concerning consecutive ad-missions with a Head AIS (HAIS) score $2, age . 18, and at least onelong bone fracture from 5/98 to 12/98, n 5 621. Areas where variationin care were assessed included: pre-hospital intubation, ICP monitorplacement, use of osmotic agents, hyperventilation, and CT scanutilization. The impact of ICP monitor use on mortality and length ofstay (LOS) was evaluated using logistic regression and linear regres-sion, respectively, to control for confounding effects of age, gender,injury severity score (ISS), shock on admission, mechanism of injury,GCS, HAIS, and head CT findings.

Results: Considerable variation in care was evident. The use of pre-hospital intubation ranged from 0–56% of patients; ICP monitor place-ment, 0–49%; use of osmotic agents, 0–63%; and hyperventilation,0–38%. The mean number of head CT scans obtained per patientvaried from 1–4, while the median time to first CT scan varied from0.3–2.4 hours. Overall, ICP monitors were placed in only 103/621patients (16%). ICP monitoring was performed in 42% of patients witha GCS # 8 and 34% of patients with an abnormal CT scan. While 57%of patients with both a GCS # 8 and an abnormal CT result had ICPmonitoring, the use of ICP monitors did not influence mortality (adjust-ed odds ratio for death, 0.89 (95% CI 0.26–3.05)). Use of ICP monitorswas associated with an increase in LOS of 1.9d (95% CI 27.5 to 11).

Conclusions: Considerable variability persists in the management ofthe head injured patient. The use of ICP monitoring in the highest riskpatient stratum did not significantly alter mortality or hospital length ofstay.

23 hour observation solely for identification of missedinjuries following trauma is not justifiedPhillip J Stephan, MD, Clifann McCarley, RN, Grant E O’Keefe, MD,Joseph P Minei, MD. UT-Southwestern Medical Center, MailingAddress: Joseph P Minei, MD; UT-Southwestern, 5323 Harry HinesBlvd.; Dallas, TX 75235-9158, USA; Tel: 214-648-7295.

Introduction: 23 hour observation for serial evaluation of trauma pa-tients with unreliable exams, intoxication, or need for further diagnosticwork-up is utilized to reduce missed injury. This study was undertakento assess whether 23 hour observation is an effective adjunct tominimize missed injury after initial emergency room evaluation.

Methods: Over a 2-year period at an urban level 1 trauma center, 6749patients were admitted and 2,458 underwent 23 hour observation. Ofthe 2,458 observation patients, 303 (12.3%) were converted to fulladmission and had charts available for review. Of these, 48 wereexcluded for incorrect classification into an observation status (knownmultiple injuries, operative procedures, etc.). The remaining 255 con-verted patients underwent detailed chart review.

Results: There were 164 (64.3%) males and 91 (35.7%) females ages15–83 (mean of 35). Reasons for conversion to full admission fromobservation status are listed in the table below.

Reason for Conversion (N 5 255) N (%) % of 2458 observed

Further evaluation of known injury 89 (35) 3.6Pain management 50 (20) 2.0Change of plan for known injury 41 (16) 1.7Social 34 (13) 1.4Psych 16 (6) 0.7Missed injury/changed x-ray reading 25 (10) 1.0

Of the 25 patients that had a missed injury or changed radiographicfinding, 10 did not have a clinically significant change in managementthat prolonged hospital stay (median LOS 5 2 days). The 15 remainingpatients had significant missed injuries (0.6% of all observed). Allrequired prolonged hospital admissions (median LOS 5 7 days) and 4underwent invasive procedures and/or surgery. No patient died from amissed injury.

Conclusions: In a cohort of over 2400 observed trauma patients, lessthan 1% remained hospitalized for significant missed injuries. Weconclude that 23 hour observation for the purpose of identifyingmissed injuries after emergency room evaluation may not be justified.

Traditional injury scoring underestimates the relativeconsequences of orthopedic injuryAJ Michaels, MD, MPH, S Madey, MD, J Krieg, MD, WB Long, MD,FACS. Legacy Emanuel Hospital, Portland, OR and the University ofMichigan, Ann Arbor, MI; A Michaels, MD Trauma Services LegacyEmanuel Hospital 2801 Gantenbien Ave Portland, OR 97227, USA(503)413-2100

Introduction: The objective of this study is to illustrate that polytraumapatients with orthopedic injuries (ORTHO) face greater challengesregarding functional outcome than those without.

Methods: A convenience sample of adult blunt force trauma patientsadmitted to a Level I trauma center was evaluated during admissionand 12 months after injury. Data were collected from the traumaregistry (Trauma OneT), chart review, and interviews. Mailed surveyswere completed 12 months after injury. The SF36 general health sur-vey and the Sickness Impact Profile work scale (SIPw) were adminis-tered at both time points. Data are presented as mean 6 SEM orpercent (%). T-tests were conducted to compare means, and ISS wascontrolled by linear regression prior to the evaluation of the role ofORTHO injury pattern on outcome measures. Significance is noted atthe 95% confidence level (p , .05).

Results: The 165 patients studied were 37.2 6 1.1 years old and 67%male. The mean ISS was 14.4 6 .59 and 61% had ORTHO injury.ORTHO patients were no different from nonORTHO in any measure ofbaseline status including the SIPw and all domains of the SF36, exceptthat the ISS was greater in the ORTHO group (15.6 6 .96 vs 12.7 6 .73,p 5 .017). Baseline SF36 values were similar to national norms.Follow-up at 12 months was 51%. Those lost to follow-up differed only

S83Vol. 191, No. 4S, October 2000 Surgical Forum Abstracts